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Applications Will Be Pr ed When Submitted Properly Completed. Be S10o Sign The Application. <br /> ., APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> IF VEHICLE INVOLVED, GIVE <br /> ENC�NEER'S AND/OR f000 ESTABLISHMENTS,HOUSINGMak@ _ <br /> APPLICANT'S AND/OR <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING <br /> REAL ESTATE INSPECTIONS LIC. No. <br /> BROKER AND/OR POULTRY RANCHES ANO KENNELS <br /> (CENSE AND/OR Regist. Na. <br /> 37RATION MISCELLANEOUS SERVICES Color <br /> I. .BER -- <br /> f C.' <br /> Application Date—am L--/ y�Business/Name To A pear On Permit _ ' Pro ro&IaCP-f <br /> yo- <br /> nType Permit/Service Requeste�d/:— �"€ � - <br /> li- <br /> z Applicant Name �i� L2 '� Address `� �K <br /> Busine�sS Teleph ne No. Emergency Telephone No. <br /> I(Property Location/Address J <br /> �j Property Owner _ Address <br /> I Address <br /> L Operator's Name <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> 1:1 RESTAURANT ❑ FOOD MARKET RETAIL 11 FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees <br /> ALL APPLICANTS: Total Employees Including Operators -- 2-70•ve <br /> 2. HOUSING <br /> ElHOTEL/MOTEL/No, of Units _ El CERTIFICATE OF OCCUPANCY <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY ❑ WATER HAULER <br /> NO. OF PUBLIC SERVED (Connections)—_ -- L <br /> 4. RECREATIONAL HEALTH ElSWIMMING POOL ❑ SPA ElWADING POOL 13 NATURAL BATHING <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds .-- FEB 0 <br /> r .ENNEL/Runways _ /Animal Population No. No. of Confining Cages 1 <br /> Sewage Disposal Method - - - - oG TAL HEA1T" <br /> Solid Waste Disposal Method - <br /> — Animal Waste Disposal Method <br /> Water Supply Source <br /> 6. ❑ CONSULTATION FEE <br /> 7, ❑ PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample 13 Title Company <br /> Sewage System Inspection ❑ Address Tele. No. <br /> Escrow No. - <br /> Seher --- Seller Address <br /> Telephone No. - Seller Agent Name _- <br /> Service Request For Date - - <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> APPLICANT'S SIGNATURE X -- Title - Date <br /> FOR DEPARTMENT USE ONLY <br /> Fee IS Duet ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 R Received By January 31 ❑ July 1 8 Received By July 31 <br /> REMIT <br /> BASE EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE <br /> a.� v is - qty �?70.p a <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Date Receipt No Permit No Issuance Date Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O.Boa 2009 STOCKTON,CA 95201 <br />